Areas to assess first unaffected areas, external before internal parts

Environment Equipment

18Physical Health Exam-General Survey

Appearance

Age, skin color, facial features

Body Structure - Stature, nutrition, posture, position, symmetry

Mobility - Gait, ROM

Behavior

Facial expression, mood/affect, speech, dress, hygiene

Cognition

Level of Consciousness and Orientation (x4)

Include any signs of distress- facial grimacing, breathing problems

19Documentation

General Appearance

Alert, and oriented X4 well nourished 40 year old male. Dressed appropriately, well groomed. In no apparent distress (NAD), in good spirits, speech clear, gait steady, and posture relaxed.

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